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Clinical Documentation Improvement Specialist - Milford, United States - Milford Fire Department - Massachusetts
Description
MondayThe 149-bed medical center is a nonprofit, acute-care facility, where more than 300 primary care and specialty physicians are committed to providing exceptional healthcare services to our community with dignity, compassion and respect.
Statement of Purpose:
The Clinical Documentation Improvement Specialist (CDS) is responsible for reviewing the medical record for technical accuracy, specificity, and completeness of provider clinical documentation.
CDSs are expected to collaborate with providers and other healthcare team members to make improvements that result in accurate, comprehensive documentation that reflects completely, the clinical treatment, decisions, and diagnoses for the patient.
Qualifications:
Education:
Bachelor of Science in Nursing preferred, or equivalent combination of relevant education/experience
Certification/License:
CCDS or CDIP is required; if not certified must be able to obtain within 2 yearsRegistered Health Information Administrator/Registered Health Information Technologist (RHIA/RHIT) or Certified Coding SpecialistIf a Nurse: Licensed Registered Nurse in MAExperience: Nurses: Minimum of 5 years clinical expertise and extensive knowledge of complex disease processes with broad experience in an inpatient setting
RHIA/RHIT/CCS:
Documented education in anatomy/physiology & pharmacologyProficient with 3M 360, or other CDI and coding software productsWorking knowledge of quality improvement theory and practiceAbility and willingness to seek out and accept changeDemonstrates adaptability and self-motivation by staying abreast of CMS rules and regulations and incorporating those changes into daily practiceProficient in federal, state, and private payer regulationsUnderstanding of Microsoft Office products: Outlook, Word, Excel, PowerPoint, Excellent oral and written communication skills with providers and other healthcare professionalsExcellent critical thinking skills, able to assess, evaluate and ability to educate providers about documentation improvement.
